Diagnosing Psychotic Disorders: Mood and Psychosis Objectives Review diagnostic criteria for mood disorders with psychosis. • Recognizing and treating comorbidities in Schizophrenia Spectrum Disorders have implications to prognosis & treatment. • Identifying comorbid disorders at time of intake (or later during psychotherapy sessions) can inform more specific medication and psychotherapy treatments and improve outcomes and prognosis. • Whereas psychiatrists have formal training in diagnosing comorbidities, often time clinical staff are responsible for intake appointments and can benefit from review of the most common comorbidities. Temporal overlap between mood and psychotic symptoms helps distinguish between primary psychotic and primary mood disorders. As a patients illness progresses, the timing of the psychotic symptoms in relation to the mood symptoms can change. The diagnosis may change over time reflecting this change in symptom pattern. Maria’s Story POLL: Of the options below, what is the most likely diagnosis? . Major Depressive Disorder . Bipolar Disorder . Schizoaffective Disorder Depressive Disorders with Psychotic Features Major Depressive Episode Major Depressive Episode Criteria > 5 of the following depression symptoms are present during the same 2-week period and represent a change from previous functioning For most of the day, nearly every day, must have either: . Depressed mood . Markedly diminished interest or pleasure in all, or almost all, activities Note: patients can have both and, if both are present, these together count as 2 of the 5 needed symptoms Major Depressive Episode Criteria Other signs and symptoms that count towards the five: 3. Significant weight loss or weight gain 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day 6. Fatigue or loss of energy nearly every day 7. Feelings of worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day 9. Recurrent thoughts of death or suicide; or suicidal ideations with a specific plan or a suicidal attempt Major Depressive Episode Criteria • Symptoms must cause clinically significant distress or functional impairment • Symptoms are not due to the physiological effects of a substance or to another medical condition A Major Depressive Episode Represents Major Depressive Disorder When… • The occurrence of the major depressive episode is not better explained by… . Schizoaffective disorder . Schizophrenia . Schizophreniform disorder . Delusional disorder . Other specified or unspecified schizophrenia spectrum and other psychotic disorders • There has never been a manic episode or a hypomanic episode Major Depressive Disorder with Psychotic Features Major Depressive Episode Psychotic Symptoms At least 2 weeks of depression during which psychosis is also present A major depressive episode has occurred concurrently with positive symptoms and/or thought disorder Depression and Psychotic Features Depression with Psychotic Features Mood-Congruent Depressive Themes . With mood-congruent Personal Inadequacy psychotic features . Guilt . With mood-incongruent . Deserved Punishment psychotic features . Disease . Death . Nihilism What if we add information What if we add information POLL: Of the options below, what is the most likely diagnosis? . Major Depressive Disorder . Bipolar Disorder . Schizoaffective Disorder Bipolar Disorders with Psychotic Features Manic & Hypomanic Episodes Manic episode criteria The first criterion relates to a change in mood lasting at least a week and present most of the day, nearly every day Note: if the patient requires inpatient hospitalization the episode does not have to last a week • There must be a distinct period of abnormally and persistently (1) elevated, expansive, or (2) irritable mood… …in addition to an abnormally and persistently (3) increased activity or energy Manic Episode Criteria Associated symptoms 4. Inflated self-esteem or grandiosity 5. Decreased need for sleep 6. More talkative than usual or pressure to keep talking 7. Flight of ideas or subjective experience that thoughts are racing 8. Distractibility 9. Increase in goal-directed activity or psychomotor agitation 10. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) Manic Episode Criteria If the patient has elevated or expansive mood Three additional associated symptoms are required If the patient has only irritable mood Four additional associated symptoms are required Manic Episode Criteria • The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. • The disturbance in mood and the change in functioning are observable by others. Manic Episode Criteria The mood disturbance is sufficiently severe to cause… . marked impairment in social or occupational functioning . or to necessitate hospitalization to prevent harm to self or others . or there are psychotic features Symptoms are not due to… . a medical condition . or the effects of a medication or substance abuse Difference Between Manic and Hypomanic Episode The mood episode lasts at least 4 consecutive days. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is by definition, manic. Bipolar I Disorder • Criteria have been met for at least one manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes. • The occurrence of the manic and major depressive episode(s) is not better explained by: . schizoaffective disorder . schizophrenia . schizophreniform disorder . delusional disorder, . other specified or unspecified psychotic disorder. Bipolar I Disorder with Psychotic Features Manic Episode Psychotic Symptoms At least 1 week of mania (or less if hospitalized) during which psychosis is also present A manic episode has occurred concurrently with positive symptoms and/or thought disorder Bipolar II Disorder • Criteria have been met for at least one hypomanic episode and at least one major depressive episode. • The has never been a manic episode. • The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Bipolar II Disorder • The occurrence of the hypomanic episode(s) and major depressive episodes is not better explained by: . schizoaffective disorder . schizophrenia . schizophreniform disorder . delusional disorder, . other specified or unspecified psychotic disorder. Bipolar II Disorder with Psychotic Features Hypomanic Episode No Psychotic Symptoms At least 2 specific lifetime mood At least 4 days of episodes are required hypomania A hypomanic episode has occurred. not hospitalized (hospitalization means it is mania) Never has had a manic episode. no psychosis (psychosis means it is mania) Bipolar II Disorder with Psychotic Features Major Depressive Episode Psychotic Symptoms At least 2 weeks of At least 2 specific lifetime mood episodes major depression are required during which psychosis is also Has had at least 1* major depressive episode present concurrently with positive symptoms and/or thought disorder *The psychotic depression must be the current or most recent episode Mania and Psychotic Features Bipolar I Disorder with Psychotic Features Mood-Congruent Manic Themes . With mood-congruent . Grandiosity psychotic features . Invulnerability . With mood-incongruent . Suspiciousness psychotic features . Paranoia . Religious . Erotomanic If the patient has psychotic symptoms only during major depressive episode(s) or manic episode(s)…. ….then the patient has a mood disorder with psychotic features If the patient has never had mood episodes … or if they have had psychotic symptoms at times other than during their mood episodes… . …then they may have a schizophrenia-spectrum disorder Mixed Features Depressive Episode with mixed features If… . ≥3 of these manic symptoms are present for most of the time . during a current or most recent episode of a depressive or persistent depressive episode . The depressive episode can be specified as with mixed features. 1. Elevated, expansive mood 2. Irritable mood 3. Increased activity or energy 4. Inflated self-esteem or grandiosity 5. Decreased need for sleep 6. More talkative than usual or pressure to keep talking 7. Flight of ideas or subjective experience that thoughts are racing 8. Distractibility 9. Increase in goal-directed activity or psychomotor agitation 10. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) Manic or Hypomanic episode with mixed features If… . ≥3 of these depressive symptoms are present for most of the time . during a current or most recent episode of mania or hypomania . This qualifies as Bipolar I or II disorder with mixed features. 1. Depressed mood 2. Markedly diminished interest or pleasure in all, or almost all, activities 3. Significant weight gain or weight loss 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day 6. Fatigue or loss of energy nearly every